INTEGUMENTARY DISORDERS

ANATOMY AND PHYSIOLOGY OF THE SKIN: LAYERS: 1. EPIDERMIS- outer layer of the skin 5 layers of Epidermis: a. Stratum Germinativum - Connects the epidermis and the dermis - Contains melanocytes ( production of melaninresponsible for the skin and hair color) Keratin - an insoluble fibrous protein that forms outer barrier of skin. - Elasticity of the skin - The ingredient of skin, hair, nails - Principle hardening - Prevent excessive fluid loss of the body Two common cells in the epidermis: Mer Langerhans- cell mediated immune response of the skin. b. Stratum - Shapes keratin cells c. Stratum Granulosum - Shapes keratin cells - Responsible for continuing mature skin cells into squams or scale like cells of the epidermis. d. Stratum Lucidum - Provides toughness - Protects from friction e. Stratum Corneum - Corneal layer - Contains squamous cells - Protects the body from harmful substances - Prevents water loss that needs to be completed or replaced within 3-4 weeks. 2. DERMIS- middle layer of the skin - contains most of the substances in the skin - composed of substances and structures of the skin and provides strength - referred to: TRUE SKIN Two layers of dermis: Papillary Dermis - lies directly beneath the epidermis - composed of fibroblasts cells which is capable of producing collagen - provides nourishment to the epidermis Reticular Dermis - Lies beneath the papillary layer - Produces collagen and elastic bundles - Responsible for strength and toughness of skin. - Made up of lymph vessels, nerves, sweat, sebaceous glands and hair roots. - Most sensitive part of skin. 3. SUBCUTANEOUS TISSUE- inner most layer of the skin. - Composed of adipose tissue - Heat insulation; keeps you warm - Provides cushion between skin layers, muscles or bones.

Calorie- reserved; stores calorie

THE HAIR grows in a cavity called HAIR FOLLICLE - Consists of root formed in the dermis in the hair shaft - Hair growth varies on body part or gender - Composed of non-viable proteins and products. - Adult scalp: 85%-90% hairs 50-100 hair loss per day NAILS- hard, transparent plate of keratin on the dorsal surface of the fingers and toes - Protects fingers and toes from - Horny scales of the epidermis - Toe nails grows faster than finger nails - Grows .1mm GLANDS OF THE SKIN: a. Sebaceous glands empty sebum onto the spore between b. Sweat glands- found in the skin all over most body surface.

Eccrine- regulates body temperature

Respond to emotional distress Physiologic stimuli

Apocrine- can be found: axilla, breasts, anal

region, labia majora,scrotum - Hormonal influences, emotional distress FUNCTIONS OF THE SKIN: 1. Protection ( bacterial and foreign matters) 2. Sensation (temperature, pain, light touch, pressure) RECEPTORS: Meissners Corpuscle - touch Merkel cells and Ruffini endings pressure Pacinian vibration and pressure Hair Follicle endings hair movement 3. Fluid balance 4. Temperature regulation (normal: 37C/ 98.6F) 5. Vitamin D production 6. Immune response function ASSESSMENT: Texture, lesion, skin turgor, color, temperature, mobility, moisture or dryness, vascularity, condition of the hair and nails PRIMARY LESIONS: 1. ERYTHEMA 2. DIAPER RASH 3. SKIN RASH 4. CYANOSIS 5. JAUNDICE 6. COLOR CHANGES 7. HYPOPIGMENTATION 8. HYPERPIGMENTATION PRIMARY LESIONS: (OTHERS) 1. MACULE- flat, circumscribed area of color change in skin without elevation of surface (ex. Skin rash) 2. PAPULE- circumscribed solid and elevated

3. NODULE- 1-2cm in diameter; solid, elevated

lesion extends into dermis 4. WHEAL- slightly irregular, transient superficial elevated of the skin with palpable margin. 5. VESICLE- circumscribed elevated lesion with filled serous fluid, less than 1cm in diameter 6. BLISTER- fluid filled vesicle/ bulla 7. BULLA- vesicle larger than 1cm in diameter 8. PUSTULE- vesicle or bulla containing purulent exudates 9. COMEDO- plugged and dilated pore, called BLACKHEAD/WHITEHEAD 10. CRUST- dried exudates over damaged epithelium; maybe associated with vesicle, bullae, pustules 11. CYST- semisolid or fluid filled mass, encapsulated In deeper layers of the skin 12. FISSURE- crack in the epidermis usually extending into dermis 13. SCALES- skin debris on the surface of epidermis THERAPEUTIC BATHS: Effects: 1. Soothe the skin 2. reduces the skin bacteria count 3. clean and hydrate skin 4. loosen scales 5. relieve itching Agents used: 1. Saline or tap water 2. Antibacterial agents - Potassium permanganate - Acetic acid 3. Colloid Substance - Oatmeal, cornstarch - Sodium Bicarbonate 4. Potassium permanganate 5. Emollients Alpha- Keri, Lubath, mineral oils THERAPEUTIC BATHS NURSING RESPONSIBILITIES: Keep the bathroom warm but adequately ventilated. Ensure that the bathwater is in a comfortable temperature that is neither too hot nor too cool. Fill the tub 1/3 to full Mix agent well with water Assist client into and out of the tub to prevent falls Instruct client to stay in bath for 20 to 30 minutes Dry client by blotting with towel. WOUND CARE: Dressing and rule of wound care: Rule1: Categorization Rule2: Selection Rule3: Change Rule4: Evolution Rule5: Practice

Categories of dressings: - Sterile or non-sterile gauzes 1. Wet dressings for acute, weeping, inflammatory lesions, vesicular, bullous, pustular and ulcerative disorder. 2. Moisture- Retentive Dressings- same function as wet compresses/ dressings but more efficient at removing exudates because of their higher moisture-vapor transmission. Hydrogels- ideals for superficial wounds, with high serous output such as abrasions, skin graft sites and draining venous ulcers. Foam Dressings- non-adherent and require secondary dressings to keep them in place -good choice for exudative wound Calcium Alginates- nonadherent and requires secondary dressing - Derived from SEAWEED - Works well when packed into deep cavity, wound or sinus tract with heavy drainage. SECRETORY DISORDERS: COMMON DIAGNOSTIC TESTS 1. Biopsy (malignancy, tumor) 2. Cutaneous immuno-flourescence biopsy (immune-mediated dermatitis) 3. Potassium Hydroxide (KOH) (Fungal infections) 4. Culture and sensitivity ( bacterial or viral infections) 5. Tzanck test (Herpes infections) 6. Skin scraping (fungal infections or scabies) 7. Patch test (allergies) SECRETORY DISORDERS: ACNE VULGARIS- common inflammatory disorder of the sebaceous glands - Characterized by comedones(acne lesions), papules, pustules, nodules and cysts Two types: Non-inflammatory reaction Inflammatory Reaction a. Non-inflammatory reaction 1. Closed Comedones (WHITEHEADS) -obstructive lesions formed from impacted lipids or oils and keratin tat plug the dilated follicle 2. Open Comedones (BLACKHEADS) -results not from dirt but from accumulation of lipid, bacterial, epithelial debris b. Inflammatory reaction 1. Closed Comedone -ruptured-- - -leakage of follicular contents into the dermis-- - - interaction with certain skin bacteria (PROPIONIBACTERIUM) PATHOPHYSIOLOGY OF ACNE VULGARIS: FACTORS: Non-Modifiable -age (adolescents)

-hormonal factors -genetic factors Modifiable -bacterial infection -cosmetics -hygiene Androgenic stimulationproduces a heightened response in sebaceous glandsglands produce too much oil/sebumplug/block pilosebaceous ductsaccumulate dirt, epithelial debris, bacteria, sebumCOMEDO FORMATION GOALS OF NURSING MANAGEMENT: - Reduces bacterial colonies - Decreases sebaceous gland activity - Prevent the follicles from becoming plugged - Reduce inflammation - Combat secondary infection - Minimize or prevent scarring - Eliminate factors that predispose the person to acne

Note: can cause CNS and Cardiovascular and structural defects abnormalities of the face (fetus) Nurse Alert!!! Mandating Contraceptive (Estrostep and OrthoTriCyclen) for 4-8 weeks to prevent toxic effects. SURGICAL MANAGEMENT: 1. Comedo Extraction incision and drainage of large nodular cystic lesions 2. Cryosurgery- freezing the lesion with liquid nitrogen 3. Intralesional steroids- injection 4. Deep Abrasive therapy (Dermabrasion)chemical skin peeling for removal of deep scars)

MEDICAL MANAGEMENT: A. PHARMACOLOGIC MANAGEMENT Keratolytics (Keratin dissolvers) Examples: Benzoylperoxide and sulfur (Benzulfoid cream; Sulfoxyl) - loosens the outer layer of the epidermis - depresses sebum production and promote breakdown of comedo plugs. Alters Keratinization Examples: 1. Tretinoin (Retin-A/ Renova) - Opens follicles and facilitates the movement of sebum to skin - Forces up comedones and prevents new comedone formation 2. Adapalene (Differin) - Same action with tretinoin - Anti inflammatory and comedolytic properties Topical antibiotics Examples: Clindamycin (Cleocin) and Erythromycin Benzoyl peroxide plus erythromycin (Benzamycin gel) Tetracycline Oral antibiotics Examples: Tetracycline Note: should not be taken with antacids or milk products Rationale: affects absorption Note: should not be give to pregnant women Rationale: affects the teeth of developing infant, causes enamel hypoplasia, discoloration of teeth Side effects: photosensitivity, nausea, diarrhea, vaginitis, candidiasis for women Oral Retinoids Examples: Isotretenoin (Acurtane) - Reduces sebaceous gland size and inhibits sebum production - Causes the epidermis to shed this causing expelling existing comedones. Adverse Reactions: Lethal to fetus